Westover Hills Rehab: Neglect Complaint Uninvestigated - TX
The resident, identified in inspection records only as Resident #1, was a woman who had come to Westover Hills Rehabilitation and Healthcare after surgery on her left knee following a fall at home. She arrived on May 10, 2026. She was there for eight days.
She was dependent on staff for everything — every activity of daily living, according to her care plan. She had a left knee surgical wound and existing skin breakdown on her right big toe when she arrived. She needed people to move her, clean her, and turn her. According to her family, those people often did not come.
On the evening of May 17, an LVN administered an enema. The following morning, staff noted a change in condition. A nurse practitioner evaluated her and ordered her sent to the hospital. The discharge record lists the reason as lethargy.
Three days later, on May 21, the family got a report from hospital nurses. Resident #1 had developed a pressure ulcer on her buttocks and another on her neck. Hospital staff told the family those wounds may have contributed to a diagnosis of systemic infection.
The family member called the nursing home. He reached the Director of Nursing. He described her as defensive and indifferent.
What happened next is the violation federal inspectors documented when they arrived on May 23, 2026, the same day Resident #1's discharge paperwork was dated in the facility's own records. The Director of Nursing and the Administrator reviewed the complaint together. They looked at nursing notes showing the two LVNs had given the enema on the night of May 17 and had not documented any skin breakdown at that time. Based on that, the two leaders concluded the allegation was without merit.
They did not open a formal investigation. They did not interview staff about the family's repeated observations during visits. They did not review whether anyone had documented repositioning, or failed to document it, across the eight days she lived there. They did not self-report the allegation to the state agency, a step the Director of Nursing acknowledged they had considered and rejected, because, she said, the allegation had no evidence.
The Director of Nursing told inspectors that Resident #1 had been admitted for long-term care rehabilitation with ADL supports, that her condition was complicated by the knee surgery, and that when the change of condition was identified on the morning of May 18, the facility acted on the nurse practitioner's orders and sent her to the hospital. She described the process as appropriate. She did not describe any investigation into what the family had witnessed during the days before that morning.
The family member's account to inspectors was detailed. He said there were days, plural, when he and other family members visited and no care had been provided. He said the family had to intervene repeatedly, insisting staff provide care. He said he grew upset when the hospital told him about the ulcers. He said when he called the nursing home, the Director of Nursing heard his complaint but he felt she was not taking it seriously.
Pressure ulcers on the buttocks are a recognized consequence of immobility. A resident who is not repositioned, not cleaned after incontinence, and left in the same position for extended periods is at risk of developing them. The inspection report does not establish that neglect caused Resident #1's wounds. What it establishes is that the facility never seriously tried to find out.
The facility's own abuse and neglect prevention policy, dated April 2001, states the program requires staff to identify and investigate all possible incidents of abuse, neglect, and mistreatment, and to investigate and report allegations within required timeframes. The policy does not appear to have guided what the Director of Nursing and Administrator did in this case. What they did was look at two nursing notes, find no documentation of skin breakdown on the night of May 17, and close the matter.
That is not an investigation. Inspectors found the facility had failed to investigate the allegation for one of three residents reviewed for abuse, neglect, and exploitation complaints during this inspection.
The deficiency was cited at a level of minimal harm or potential for actual harm. That classification reflects where regulators placed the finding on their severity scale, not a judgment about what happened to Resident #1. She had left the building five days before inspectors arrived. She was in the hospital.
What the family described, if accurate, is a woman who needed staff to move her every few hours, who had a fresh surgical wound on her knee, who had existing skin breakdown when she arrived, and who spent eight days in a facility where, on multiple occasions, the people responsible for her care did not come. The family came instead. They asked. They insisted. Then she developed ulcers on her back and neck and was sent to the hospital with a systemic infection, and when her family called to say something had gone wrong, the Director of Nursing heard them out and, with the Administrator, decided nothing had.
No one from the facility contacted the state. No one interviewed the floor staff about the family's observations. No one reviewed whether repositioning had been documented or skipped across those eight days.
The family member told inspectors he felt the Director of Nursing was defensive.
The Director of Nursing told inspectors the allegation had no evidence.
The inspectors found that the facility had never looked for any.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westover Hills Rehabilitation and Healthcare from 2026-05-23 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 17, 2026 · Our methodology
WESTOVER HILLS REHABILITATION AND HEALTHCARE in SAN ANTONIO, TX was cited for neglect violations during a health inspection on May 23, 2026.
She was dependent on staff for everything — every activity of daily living, according to her care plan.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.